ALTERNATIVE TREATMENTS FOR MENISCAL INJURIES

ALTERNATIVE TREATMENTS FOR
MENISCAL INJURIES
INSTRUCTIONAL COURSE
LECTURE
R. VERDONK
From Ghent University Hospital, Belgium
Historical review. “By arterial injection with an opaque
medium, one can discern a network of fine vessels from the
capsule, entering the convex border of the meniscus but
disappearing almost immediately. Because of this, one
might expect healing in peripheral meniscus detachments,
but none in tears limited to the semilunar cartilage itself”.
These were the opening sentences of King’s paper at a
meeting of the American Academy of Orthopaedic Surgeons in St Louis, Missouri on 13 January 1936. He
performed several experiments to assess the healing capacity of the internal semilunar cartilage of the knee in dogs.
Incisions made in and around the semilunar cartilages
seemed to heal to a varying degree in relation to contact
with the synovium on the outer edge of the meniscus.
These findings indicated that (Fig. 1): 1) tears confined to
the semilunar cartilage probably never heal; 2) a torn
meniscus may heal by connective tissue if the tear communicates with the synovial membrane; 3) a complete transverse or oblique tear results in some separation of the
fragments and within three weeks the intervening space fills
with firm connective tissue arising from the synovium,
indicating the time necessary for complete fixation; and 4)
a meniscus partially torn from its peripheral attachment
heals readily in a normal anatomical position.
Why save the meniscus? On 16 November 1883 Thomas
Annandale was the first to suture a medial meniscus, but
arthrotomy and meniscectomy have since become common
orthopaedic procedures. In the 1950s and the 1960s total
meniscectomy was performed for almost any meniscal tear
suspected on clinical examination. In the last two decades,
arthroscopy has allowed adequate meniscectomy, following
1
the technical rules laid down by authors such as Jackson.
Between 1970 and 1980 it was shown that a carefully
executed arthroscopic meniscectomy for a torn medial
meniscus provided full functional restoration in more than
90% of cases, with short-term results comparable with
those of open meniscectomy. In the longer term, factors
such as varus malalignment and mechanical overload
increase the risk of degeneration of load-bearing cartilage
(Fig. 2). The buffer function of the semilunar cartilage
between the femoral condyle and medial tibial plateau is
lost, and the stabilising factor, the meniscal wall, is also
lacking. The result is an increased anteroposterior shift of
the femoral condyle in relation to the medial tibial plateau
(Fig. 3). Any ligamentous laxity produced by the initial
trauma will increase the degenerative changes in the loadbearing area. Even more important, but less controllable, is
the magnitude of the mechanical load. This will depend on
the weight of the patient and on work- and sports-related
activity.
The same factors also apply to older patients. The shortterm results of accurate arthroscopic meniscectomy are
better than those of open total meniscectomy because of the
preservation of the meniscal wall. Again, the quality of the
load-bearing cartilage will determine the functional out-
Fig. 1
R. Verdonk, Professor of Orthopaedic Surgery
Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
Updated text and illustrations, printed with the permission of EFORT. The
original article appears in European Instructional Course Lectures Vol. 3,
1997.
866
Diagram to show a tear in the meniscus which probably never
heals (1), a tear which probably heals by connective tissue since it
communicates with the synovial membrane (2), a complete transverse or oblique tear which heals by connective tissue arising from
the synovial membrane (3), and a partial tear of the meniscus from
its peripheral attachment which will readily heal in its anatomical
position (4).
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ALTERNATIVE TREATMENTS FOR MENISCAL INJURIES
Fig. 2
After medial meniscectomy, factors such as varus malalignment and
mechanical overload increase the risk of degeneration in the load-bearing
medial compartment.
867
come in this age group and, in the long term, only 50% of
the patients will continue to benefit.
These poor to fair results in older patients draw attention
to the negative consequences of meniscectomy and suggest
that meniscal suture should be performed whenever this is
feasible. A functionally competent knee and an anatomical
2
restoration can be expected in 90% of cases.
If chondral congruity is indeed improved by the presence
of the medial meniscus under loading conditions, then this
also applies to the lateral compartment. The convex lateral
femoral condyle articulates with an almost convex lateral
tibial plateau. The contact area between the joint surfaces is
flattened and widened only because of the presence of the
O-shaped lateral meniscus. More caution is necessary in the
treatment of a lateral meniscal lesion than of a torn medial
meniscus. Clinical experience has shown that problems
may arise even after the correct and adequate resection of a
torn lateral meniscus.
MENISCAL FUNCTION
Fig. 3
Load-bearing function. Since degenerative changes are
3,4
often observed after meniscectomy it has been suggested
that the menisci have an important role in load transmission
5
across the knee. In non-loaded conditions the contact is
primarily on the menisci (Fig. 4). Load-bearing areas in the
normal knee have been measured. Only 10% of the cartilage is in contact at no load, and this is restricted to an area
close to the medial tibial spine (Fig. 4). Under load, contact
occurs both on the menisci and on the exposed articular
6
cartilage. It was shown by Ahmed and Burke that 50% of
the compressive load was transmitted through the menisci
in extension (Fig. 5) and 85% at 90° of flexion (Fig. 6).
These findings confirm that the menisci transmit a sig-
After total meniscectomy an increased anteroposterior shift can
be expected.
Fig. 4
In vitro measurement of the load-bearing function of
the menisci shows that in non-load conditions the contact areas are primarily on the menisci. About 10% of
the cartilage is in contact in non-load conditions, near
the medial tibial spine.
VOL. 79-B, NO. 5, SEPTEMBER 1997
Fig. 5
Fig. 6
Figure 5 – In vitro measurement of the load-bearing function of the
menisci shows that 50% of the compressive load is transmitted through the
menisci in extension. Figure 6 – In vitro measurement of the load-bearing
function of the menisci shows that 85% of the compressive load is
transmitted through the menisci at 90° of flexion.
868
R. VERDONK
a squeeze-film mechanism in which load-bearing surfaces
move perpendicularly towards each other. The actual knee
7
lubrication mechanism is elastohydrodynamic in nature.
MENISCAL REPAIR
Fig. 7
‘One-two-three’ knee: one stands for rupture of the anterior cruciate
ligament, two for subsequent medial meniscectomy, and three for final
lateral meniscectomy and severe incapacity.
nificant part of the load from the femur to the tibia.
Shock absorption. Because of their visco-elasticity, the
menisci attenuate shock waves generated by impulse loading in normal gait.
Maintenance of joint stability. There is no agreement
about the stabilising role of the menisci. Increased laxity
7
has been reported after meniscectomy but other studies
8
show no such increase. Meniscectomy in a ligamentdeficient knee, especially with lack of the anterior cruciate
9
ligament, significantly increases joint laxity. Degenerative
evolution after such combined lesions has been observed,
and has been referred to as the ‘one-two-three knee’ (Fig.
7). ‘One’ stands for solitary rupture of the anterior cruciate
ligament (ACL), ‘two’ for subsequent medial meniscectomy and ‘three’ for final lateral meniscectomy, which
ultimately leads to severe incapacity.
Joint lubrication. Two of the several forms of lubrication
should be considered: boundary lubrication and fluid film
lubricant. Lubricin appears to function as a boundary lubricant in synovial joints. There are two different forms of
fluid film lubrication: a hydrodynamic mechanism in which
load-bearing surfaces work tangentially on each other, and
Fig. 8
Except for cases with associated lesions for which an open
arthrotomy is required, meniscectomy should always be
performed arthroscopically. This improves the efficiency of
the procedure. Nevertheless, meniscal repair should always
be considered during evaluation. Important factors are the
clinical signs of associated lesions, and the type, location
and extent of the meniscal tear. Clinical evaluation remains
the basic source of information, with other clinical factors
and clinical assessment of the contralateral knee to complete the findings. Complementary investigations such as
CT and MRI may also be needed. The ultimate treatment
decision should be based on an arthroscopic protocol,
which specifies the extent of the lesion and the condition of
the other intra-articular structures.
Subdivision of tears based on treatment
Masterly neglect. Some meniscal tears should be left
untreated if they are minimal, not exceeding 1.5 mm in
length, and do not correlate with clinical findings. Small
partial-thickness split tears can also be left untreated especially if the patient has a low level of physical activity
(Fig. 8).
Suture or excision? This dilemma arises when tears are
considered along with the history and the clinical findings.
These factors are important in the choice between partial
meniscectomy, meniscal suture, meniscal welding (Jackson
1996, personal communication), or partial meniscal
replacement (Steadman 1996, personal communication).
Only the peripheral 25% of the meniscus is vascularised,
the remainder deriving nutrition from synovial fluid. A tear
involving the vascularised area at the junction of the capsule and meniscus is designated a ‘red-on-red’ tear, one in
Fig. 9
Figure 8 – A small partial-thickness split tear of the lateral meniscal body can be left untreated, especially if the patient has a low
level of physical activity. Figure 9 – A red-on-red tear mainly involving the medial meniscal rim should always be sutured.
THE JOURNAL OF BONE AND JOINT SURGERY
ALTERNATIVE TREATMENTS FOR MENISCAL INJURIES
the avascular, most central, part of the meniscus a ‘whiteon-white’ tear, and one at the junction between the vascular
and avascular areas a ‘red-on-white’ tear. From my own
series, I conclude that red-on-red tears should always be
sutured (Fig. 9); they carry the best prognosis because of
the vascularity of the meniscus in that area. By contrast,
white-on-white tears form an absolute contraindication.
Decisive factors in red-on-white tears are the extent, the
location and particularly the aspect of the tear, and its acute
or chronic nature. Acute tears have a much better prognosis
for healing after suture.
ALTERNATIVE TREATMENTS
Meniscal welding. Laser beams have been used to resect
menisci, smooth out articular cartilage, release soft tissue,
shrink collagen in shoulder surgery, and remove degenerative discs in spinal surgery. In the future, tissue welding
with covalent bonding of collagen fibres by laser-activated
photodynamic methods is a distinct possibility. The stimulatory, genetic and mutagenic effects of laser therapy,
however, must be studied in greater depth.
Partial meniscal replacement. ReGen Biologics (Sulzer
Orthop¨adie AG, Baar, Switzerland) have developed a collagen-based device designed to stimulate regeneration of
meniscal tissue to replace damaged or deficient host tissue.
This collagen meniscus implant (CMI) appears to support
regeneration of meniscal tissue. In accordance with a concept of guided tissue regeneration the collagen matrix
provides a template for cellular infiltration and deposition
of a new matrix. If successful, the regenerated tissue would
provide many of the functions of the normal meniscus and
also protect the joint.
Animal studies in vivo have shown that a CMI can
support meniscal regeneration in animal knees, and good or
excellent results have been obtained in pigs. Similar results
were achieved in 62% of knees in the first canine study.
During this experimental study, improvements were made
in implant design and construction, and the cross-linking
agent was changed to give more uniformity and stability.
Gamma irradiation was used to sterilise the implant thus
avoiding the potential toxic residuals from the ethylene
oxide sterilisation used previously.
In a clinical feasibility study of the first ten patients the
implant supported cellular infiltration and tissue ingrowth.
The regenerated tissue at six months had a chondroid-like
histological appearance.
869
important, as well as the problems after meniscectomy
associated with ligamentous rupture in ACL-deficient
knees. The treatment of ligamentous instability has been
improved by the use of tendon allografts instead of syn10
thetic devices, and the promising short-term results made
us reconsider meniscal transplantation. Meniscal allografts
could replace the shock-absorbing and spacer functions
which are defective in ACL-deficient knees. Previous
attempts using meniscal allografts in dogs gave satisfactory
results regarding the fixation and the recovery of normal
11,12
and
metabolic and mechanical properties at six months,
13,14
their clinical use has been advocated.
Meniscal preservation techniques. Various methods can
be used to preserve fresh meniscal allografts. Differing
results have been obtained with cryopreservation. Shortterm storage does not appear to affect the morphological
15
appearance or biochemical characteristics of the menisci.
Biosynthetic activities, however, are decreased to less than
50% of normal control values and only 10% of transplanted
meniscal cells have metabolic activity.
The early results obtained with gamma-sterilised, lyophilised meniscal allografts indicated excellent fixation of the
meniscal body, but the fine architecture of the meniscus
16
was totally disrupted and the tissue was non-viable. In
solvent-dried menisci the collagen bundle has a fairly
normal structure, but they are also non-viable. Because of
14
the successes reported by Zukor et al in the transplantation of fresh allografts, we have opted for a fourth option,
meniscal culture.
Meniscal culture. Donor menisci are removed in an operating room under strict aseptic conditions during the procurement of other organs from heart-beating (multipleorgan donors) or non-heart-beating donors (Fig. 10). The
cold ischaemia time must not exceed 12 hours, during
which the meniscus remains viable. Through a transverse
arthrotomy, the lateral collateral ligaments and cruciate
ligaments are divided and the knee is dislocated anteriorly.
MENISCAL TRANSPLANTATION
In view of the satisfactory clinical results and the physical
integrity of the semilunar cartilage obtained in the long
term with arthroscopic meniscal suturing techniques, we
are considering a treatment for chronic forms of degenerative meniscal pathology. In young patients the deleterious
effects of meniscectomy on the load-bearing cartilage are
VOL. 79-B, NO. 5, SEPTEMBER 1997
Fig. 10
The medial and lateral menisci are removed with some synovial attachment allowing for atraumatic manipulation.
870
R. VERDONK
Fig. 12
The meniscal allograft, ready for implantation, is threaded with 6 2.0
PDS sutures mounted on dual needles (PDS: polydioxanone sutures).
Fig. 11
The original meniscal remnant (right) is removed from the medial compartment. The viable meniscal allograft (left) has a much larger loadbearing surface, which reduces the risk of degenerative cartilaginous
changes.
The lateral and medial semilunar cartilages are inspected
for macroscopic tears or degenerative changes, and macroscopically intact specimens are removed for experimental
investigation or clinical use. Both menisci of each knee are
removed with a small synovial rim for manipulation. The
meniscus itself is treated in a strictly atraumatic fashion.
We have evaluated 23 menisci removed for experimental
investigation.
For in vitro culture immediately after harvesting the
menisci are placed in Dulbecco’s modified Eagle’s medium
with 0.002 M L-glutamine, 1/1000 antibiotic-antimycotic
suspension (streptomycin 10 g/ml, penicillin 10 U/ml,
fungizone 0.025 g/ml) and 20% fetal calf serum. The
recipient’s serum is used for clinical applications. The
menisci are stored in a plastic container (DANCON;
Teknunc-4000 Roskilde, Denmark) to which 70 ml of incubation medium are added. The containers are placed in a
modular incubation chamber (Flow Laboratories, Del Mar,
California) at a constant temperature of 37°C and under
continuous air flow (95% air and 5% CO2). Humidity is
controlled by placing an open receptacle filled with sterile
water in the incubation chamber. The incubation media are
17
replaced every three days.
Clinical experience
Material and methods. Since January 1989 we have treated
60 patients with viable meniscal allografts. The first 40
cases are included in this study terminating in September
1994. The mean follow-up was 3 years 1 month (1 year to
6 years 2 months). There were 31 men and 5 women; 23
had transplantation of the medial meniscus and 17 of the
lateral meniscus. The mean age at the time of surgery was
35 years 10 months (23 years 5 months to 49 years 10
months). Meniscal transplantation was performed on its
own in 24 patients, combined with a valgus osteotomy in
ten, and with an intra-articular reconstruction of the anterior cruciate ligament using a tendon allograft in one
10
patient. Lateral meniscal transplantation was associated
with a supracondylar femoral varus osteotomy in one
patient.
Operative technique. Under epidural anaesthesia the patient
is placed supine and a tourniquet applied. Medial anterior
arthrotomy is performed and the cartilage of the medial
compartment is inspected. In most cases the arthroscopically diagnosed osteoarthrotic changes are confirmed. The
small meniscal rim does not provide adequate protection of
the load-bearing cartilage and is resected down to the
meniscosynovial junction until a potentially bleeding surface of synovial lining is exposed (Fig. 11). Resection of
the posterior attachment of the meniscal remnants is difficult through an anterior approach alone, and a posteromedial incision is added to facilitate transplantation and
remove the meniscal rim to the posterior aspect of the
meniscosynovial junction. These two incisions do not compromise the medial collateral ligament and the whole of the
medial compartment can be inspected.
The meniscal allograft is prepared, rinsed and threaded
with 5 or 6 2.0 polydioxanone (PDS) sutures mounted on
dual needles (Ethicon; Ethnor J.J, Neuilly, France) (Fig.
12). The allograft is implanted from posterior to anterior.
The posterior horn is sutured in position by trans-synovial
stitches and the allograft secured to the freshened meniscosynovial lining. Three PDS sutures are usually sufficient to
stabilise firmly the posterior portion of the meniscus. At the
medial aspect the exposure is extended subcutaneously so
that the allograft can be implanted by the same technique.
The anterior horn of the medial meniscus is sutured in its
original position by two PDS stitches.
The synovium is then closed posteriorly and anteriorly
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ALTERNATIVE TREATMENTS FOR MENISCAL INJURIES
871
Fig. 13
Fig. 14
The threaded viable meniscal allograft is inserted from posterior to
anterior. An osteotomy of the femoral insertion of the lateral collateral
ligament allows easier access to the posterolateral corner of the lateral side
of the knee.
Homogeneous signal intensity on MRI six months after medial
meniscal transplantation. A small intra-articular effusion is
present.
by synoviomeniscal sutures, which provide further stabilisation of the allograft, and a probe is used to confirm that
the transplant is in the correct position. The wounds are
closed, with drainage, and a plaster cast is applied.
For transplantation of the lateral meniscus a lateral
parapatellar arthrotomy is used and the articular cartilage is
inspected. The residual rim of the meniscus is resected to
obtain a potentially bleeding surface and a second counter
incision may be required in the posterolateral corner. The
posterior remnants are resected and the threaded allograft is
inserted from posterior to anterior and sutured as described
for the medial meniscus. The presence of the common
peroneal nerve in the posterolateral corner of the knee
poses a technical difficulty. Since the popliteus muscle and
the lateral collateral ligament are also in this corner, osteotomy and removal of the proximal insertion of the lateral
collateral ligament are an efficient alternative (Fig. 13).
This facilitates removal of the meniscal remnants and
implantation of the lateral meniscal allograft without jeopardising the common peroneal nerve.
In the first ten cases we used immobilisation in a plaster
cast for six weeks, but this period was progressively
reduced. Rehabilitation is now started immediately after
surgery; we use plaster-cast immobilisation only in those
patients who are not willing to comply with the treatment
protocol or for eight days for pain relief. Flexion-extension
exercises without rotatory load are encouraged. After six
weeks progressive weight-bearing is allowed.
Clinical evaluation. We attempted to use an objective rating
system to evaluate the results of meniscal allografting. The
operative technique of meniscal transplantation is itself
straightforward, but in 12 of our 40 cases additional procedures were performed, consisting of an osteotomy in 11 and
an ACL-plasty in one. These combined interventions can18,19
not be assessed using ligamentoplasty rating systems.
We therefore considered that meniscal transplantation,
performed as an isolated or combined procedure, was
comparable with an arthroplasty, and used the Hospital for
20
Special Surgery (HSS) knee rating system to assess pain,
stability and function. Flexion and extension contractures,
malalignment and the use of crutches scored minus
points.
This evaluation was correlated with the objective findings of imaging. MRI of the menisci was essential to try to
confirm ingrowth of the allografted material to the synovial
wall. MRI also provides information on cartilage quality
and ligament reconstruction. All 40 patients in our study
had MRI, although not at regular intervals (Fig. 14).
Arthroscopic evaluation was performed only to obtain
material for histological studies and to assess the aspect and
firmness of meniscal fixation.
Complications. Four patients had transient synovitis; white
cell counts suggested mechanical synovitis in three and
inflammatory synovitis in one. The mechanical synovitis
resolved spontaneously after a short period of time. The
patient with inflammatory synovitis had an abnormal white
cell count, but eventually regained normal function of the
knee. Other signs of infection also returned to normal
levels. Manipulation under anaesthesia was necessary in
three patients.
Results and discussion. There were no strict selection
criteria for including patients in our study. Young patients
with mechanical complaints who had already undergone
one or several meniscectomies were considered for inclusion. Only one patient complained of knee instability due to
ACL deficiency. In 11 patients, mechanical complaints
were ascribed to manifest axial malalignment. Because the
patient population was too divergent we did not regularly
use scoring systems in the evaluation of the 40 cases.
The principal indication was intractable pain not responding to analgesics. Based on the experiments of Wirth
13
14
et al and Zukor et al we offered them meniscal
VOL. 79-B, NO. 5, SEPTEMBER 1997
872
R. VERDONK
Fig. 15
Fig. 16
Viable cells are present in the anterior horn four months postoperatively.
Some fibrin covering is observed (haematoxylin and eosin x 220).
MRI showing that the medial meniscal transplant is firmly fixed to
the meniscosynovial junction in the posteromedial corner*. Slight
atrophy of the medial meniscal anterior horn is also shown.
Fig. 17
The mean HSS score decreased slowly and slightly,
especially between the fifth and sixth years.
transplantation.
In deep-frozen or gamma-sterilised, lyophilised menisci,
there are some alterations to the structural integrity of the
meniscal body. Because of the potential for disease transmission implantation of allografts must not be delayed for
17
too long after harvesting. The work of Verbruggen and
21
Verbruggen et al on cartilage metabolism and cartilage
cell structures allowed us to culture the entire harvested
semilunar cartilages so that viable material could be
implanted.
It has been established that fibrochondrocytes in a colla22
gen structure migrate from the synovial rim and we
therefore assumed that the production of proteoglycan
would be more efficient if viable material could be implanted on the same day as harvest. Proteoglycan production
was studied in vitro in meniscal cultures in medium supplemented with FCS. It was found to be maximal, both
qualitatively and quantitatively, after a culture period of 10
to 14 days.
No major clinical complications were encountered in our
series of 40 patients, although not all had the same operative procedures. Repeat arthroscopy was performed on 12
patients at up to two years after surgery; all showed viable
meniscal tissue, both macroscopically and microscopically
(Fig. 15).
DNA fingerprinting of the cells cultured from the harvested material in the same 12 patients showed matching
in four patients, non-matching in three and both matching
and non-matching in one. This means that at a two-year
follow-up slow ingrowth had occurred in the meniscal
transplant while some donor cells were still surviving,
suggesting chemical activity in the meniscal transplant
from the first day of transplantation. These findings were
confirmed on MRI; no major differences in contrast were
seen (Fig. 16).
The mean HSS score decreased slowly and slightly,
especially between the fifth and sixth years (Fig. 17). In
the first year, an arbitrarily chosen score of over 175
points was achieved in 72% of the patients. After four
years, 67% of the patients still scored higher than 175,
22% scored between 100 and 175, and 11% scored below
100. Three patients who had received five meniscal transplants (two bilateral) eventually had total knee
arthroplasty.
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ALTERNATIVE TREATMENTS FOR MENISCAL INJURIES
Table I. Statistical results for function in viable meniscal transplants
p value*
Pain
Stability
Anteroposterior
Mediolateral
Gait
Stair-climbing
ROM
Flexion contracture
Extension lag
0.0000
0.0099
0.412
0.0066
0.0034
0.2188
0.1936
0.2568
* <0.05 is significant
Statistical analysis using the Wilcoxon matched-pair
signed-rank test showed significant differences, with
marked improvement in pain, postoperative antero-
873
posterior and mediolateral stability, gait and stair-climbing
(Table I). There was no difference in the pre- and postoperative range of motion, flexion contracture or extension
lag (Table I).
We do not yet know whether the long-term survival of
donor cells, with the slow ingrowth of host cells into the
transplanted meniscus, will have any effect on the longterm functional results. Postoperative follow-up is much
too short to allow valid conclusions. From a technical
viewpoint, however, allografting appears to have no negative effect on the clinical findings.
The author acknowledges and appreciates the contributions of Erwin
Groessens, MD and Tom Lootens, MD. He wishes to thank Iris Wojtowicz
and Monique De Pauw for the research and typing of this text, and Marc
De Ganck for the figures. He also wishes to thank Robert W. Jackson, MD
for permission to include his research on meniscal welding, and Richard
Steadman, MD for permission to include his work on partial meniscal
replacement.
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